Child Health Clinical Record
These forms are available for providers to use as a documentation tool for all required checkup components. They should never be given out as a client questionnaire. The forms are recommended for your use by Texas Health Steps; they are not required.
Please note that forms have been updated to reflect July 1, 2018, Texas Health Steps policy changes for ages birth through 12 months and 12 to 18 years old. More details about these policy changes can be found on the Medical Providers page.
How to Download Child Health Record Forms
Go to the Texas Health Steps online catalog and click on the Browse button. Under Main Menu, click on View Catalog Items, then Child Health Records located on the left navigational pane. Select the record for the appropriate age, then click on the yellow starburst to download a printable and fillable PDF.
How to Use Child Health Clinical Record Forms
Please review these written instructions for using Child Health Record forms (PDF). The PDF forms include fillable fields (text fields, check boxes, etc.) so that you can complete the forms using Adobe Reader. Visit the File Viewing webpage for information on downloading Adobe Reader.
Developmental and Mental Health Screening
- Ages and Stages
- M-CHAT™ or M-CHAT-R/F™ (Modified Checklist for Autism in Toddlers, Revised with Follow-Up)
- Edinburgh Postnatal Depression Scale
- Postpartum Depression Screening Scale
- Patient Health Questionnaire (PHQ-9)
- Pediatric Symptom Checklist (PSC-17)
- Pediatric Symptom Checklist (PSC-35)
- Pediatric Symptom Checklist for Youth (Y-PSC)
- Patient Health Questionnaire Modified for Adolescents (PDF)
- Car, Relax, Alone, Forget, Family, and Trouble Checklist
- Patient Health Questionnaire for Adolescents (PHQ-A [anxiety, eating problems, mood problems and substance abuse screen]) (PDF)*
- Patient Health Questionnaire for Adolescents (PHQ-A) Manual and Scoring Instructions (PDF)*
- Texas Health Steps Postpartum Depression Screening Provider Tool (PDF)
*Reused with permission from the American Academy of Pediatrics, Addressing Mental Health Concerns in Primary Care: A clinician's Toolkit, American Academy of Pediatrics, June 23, 2010.
These documents are part of the American Academy of Pediatrics' Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit, which is designed to provide primary care clinicians guidance to enhance the quality of mental health care children and adolescents receive, whether in the medical home itself or through the medical home. The toolkit brings together more than 250 resources and tools on one quick reference CD-ROM and is available for purchase online.
Hearing Screening Questionnaire
ECI Referral Form
Texas Health Steps Provider Outreach Referral Form
The Texas Health Steps Provider Outreach Referral form should be used by all providers who submit a referral on behalf of a THSteps patient who needs assistance:
- Scheduling a follow-up appointment.
- Rescheduling a missed appointment.
- Scheduling transportation to an appointment.
- With other outreach services.
The following limitations and restrictions apply to the use of the THSteps Provider Outreach Referral form:
- Only one referral form can be used for up to two patients in a household; if there are more than two patients in the same household, an additional referral form must be used.
- Referrals should not be submitted for patients who are 21 years of age or older or are insured by the Children's Health Insurance Program.
The referral form is available in either Microsoft Word or Portable Document Format (PDF), and can be completed by hand or electronically and faxed using the coversheet included with the form. Download the instructions (PDF) for more information.
THSteps providers who have questions about the referral form, or need information about the THSteps Provider Outreach Referral Service, should contact the appropriate THSteps Provider Relations representative in their region (PDF).